Provider Demographics
NPI:1932462819
Name:TISDALE, WHITNEY (SLP)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CHEROHALA CT
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-3428
Mailing Address - Country:US
Mailing Address - Phone:404-702-5965
Mailing Address - Fax:
Practice Address - Street 1:2395 WALL ST SE STE 170
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6703
Practice Address - Country:US
Practice Address - Phone:404-702-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist